Epidural blood patch Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip.Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi Medical college and research institute , puducherry India
Epidural blood patch
Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip.Diab. DCA, Dip.
Software statistics PhD (physio)
Mahatma Gandhi Medical college and research institute , puducherry India
Definition
• Administration of 15 to 20 mL of the patient’s
blood, aseptically obtained, into the epidural
space possibly to treat a postdural puncture
headache is called an epidural blood patch
It was accidentalin 1930’s
• Gormley stated that the incidence of PDPH was lower than anticipated after inadvertent bloody spinal taps.
• Ozdil claimed a 100 percent success rate in preventing PDPH undergoing spinal anesthesia by depositing 2.5 ml of clotted autologous blood epidurally as the spinal needle was being withdrawn.
• DiGiovanni popularized and named it
Indications
• PDPH incapacitating with characteristic features
• not been relieved by 2-3 days of conservative management but
• no active neurological disease• no infection Iocalised to the lumbar area or
septicaemia,• no coagulopathy
Indications other than postdural puncture headache
• case of intracranial hypotension caused by spontaneous CSF leak originating at the C2 level, treated by an epidural blood patch performed at the site of the leak.
• non-surgical treatment of lumbar cerebrospinal fluid fistula
Procedure
• Preferably, 48-72hrs after the puncture which caused the PDPH
• Consent • Premed • IV crystalloid • (L) lateral position – fully flexed
Procedure
• two-operator technique• Both should scrub gown
• Operator 1.• 1. Cleans and drapes the patient's back using a
standard epidural kit and technique,• 2. Identifies the site of original puncture and
locates the epidural space using a standard technique
Procedure
• Operator 2• cleans and drapes the antecubital area of
(usually) the left (downside) arm.• When epidural space is located by operator 1,
the second operator performs a venepuncture, withdraws 22ml of blood, hands the syringe to the first operator (without breaching the integrity of the sterile fields) - sterile dressing to the venepuncture site (unheparinized blood)
How should the blood should be injected?
• 1. Inject the blood slowly until either, the patient complains of tightness in the buttocks, lower back or thighs (usually when 12 to 15ml are injected)
• 2. Withdraw needle, apply sterile dressing, turn supine.
• 3. Inject residual blood to a fresh, sterile needle into a blood culture bottle and send for C/S
Post procedure advice
• Rest with pillow under the knees for half an hour.
• No straining • No bending • No heavy weight carrying for 2 – 3 weeks • PATCH BLOW OUT • Report for fever, backache PDPH
Why use – results fascinating • EBP has an extremely high success rate of close
to 100% when placed in the epidural space at the same level as the initial needle puncture
• Less than 2% will also have mild, transient paraesthesiae, neck pain or radicular pain
• should not cause obliteration of the epidural space, infection, cauda equina syndrome or adhesive arachnoiditis
Possible mechanisms
• The blood patch works as a gelatinous glue which prevents CSF leakage and allows the dural hole to heal
• Blood may also be forced through the dural puncture forming a plug .
• The immediate relief from PDPH may be due to an increase in CSF pressure.
Other areas
• Epidural blood patch has traditionally been performed in the lumbar area, with few cases reported in the thoracic and lower cervical spine ( upto C 2)
• Caudal Epidural Blood Patch for the Treatment of Postdural Puncture Headache
• Other gadgets ?
Flouroscopic control
CT guided EBP
Then why not ultrasound
15 – 20 ml ??
• smaller volumes of blood in older and shorter patients.
• This may also be true in pregnant patients
• 7.5 ml and 10 ml are reported instead of 15 ml in these patients
Complications
• Transient paresthesias in their legs and toes, stiff neck,
• abdominal cramping, • tinnitus,• vertigo during the blood injection.• Later mild backache and fever • Neurological sequalae – epidural abscess
formation and adhesive arachnoiditis very rare
If bleeding occurs during EBP
• the procedure should be discontinued, since subsequent hematoma formation may cover the dural hole
• the addition of the EBP may lead to nerve root compression.
• If fails, second blood patch is administered.
Other causes of headache • Migraine • PIH • CVT • Subdural haemorhage • Cerebral tumour • Nonspecific • Meningitis
Epidural saline
• Large volumes of saline deposited in the
epidural space will relieve PDPH but saline is
readily absorbed and consequently the relief
produced may only be temporary
Thank you all